1. Marfan syndrome is an inherited disorder of connective tissue that affects many parts of the body, including the skeletal, ocular, cardiovascular and pulmonary systems.
2. It is caused by mutations in the FBN1 gene which results in abnormal fibrillin protein and connective tissue abnormalities.
3. Diagnosis is based on assessments of the skeletal, ocular, cardiovascular and other body systems compared to established diagnostic criteria such as the Ghent nosology, with a focus on assessments of the aorta and lenses.
Marfan syndrome - a detailed study ( all medical information )martinshaji
Marfan syndrome is an inherited disorder that affects connective tissue — the fibers that support and anchor your organs and other structures in your body. Marfan syndrome most commonly affects the heart, eyes, blood vessels and skeleton.
People with Marfan syndrome are usually tall and thin with disproportionately long arms, legs, fingers and toes. The damage caused by Marfan syndrome can be mild or severe. If your heart or blood vessels are affected, the condition can become life-threatening.
Treatment usually includes medications to keep your blood pressure low to reduce the strain on weakened blood vessels. Depending on the severity of your symptoms and the part of your body that's affected, surgery may be necessary.
please comment
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AR inherited disorder of impaired copper excretion characterized by excessive deposition of copper in many tissues and organs, principally the liver, brain, and eye. • Discovered by Samuel Alexander kinnier Wilson. Liver fails to excrete sufficient Cu via the bile, and the ability to incorporate Cu into CP is diminished Due to loss of function mutations of the ATP7B gene on chromosome 13, which encodes a copper-transporting ATPase (ATP7B). Most common presentations are with liver disease or neuro- psychiatric disturbances. Kayser–Fleischer ring is the clinical hallmark of WD. caused by deposition of copper in Desçemet’s membrane of cornea. Penicillamine is the of choice.
Marfan syndrome - a detailed study ( all medical information )martinshaji
Marfan syndrome is an inherited disorder that affects connective tissue — the fibers that support and anchor your organs and other structures in your body. Marfan syndrome most commonly affects the heart, eyes, blood vessels and skeleton.
People with Marfan syndrome are usually tall and thin with disproportionately long arms, legs, fingers and toes. The damage caused by Marfan syndrome can be mild or severe. If your heart or blood vessels are affected, the condition can become life-threatening.
Treatment usually includes medications to keep your blood pressure low to reduce the strain on weakened blood vessels. Depending on the severity of your symptoms and the part of your body that's affected, surgery may be necessary.
please comment
thank you
AR inherited disorder of impaired copper excretion characterized by excessive deposition of copper in many tissues and organs, principally the liver, brain, and eye. • Discovered by Samuel Alexander kinnier Wilson. Liver fails to excrete sufficient Cu via the bile, and the ability to incorporate Cu into CP is diminished Due to loss of function mutations of the ATP7B gene on chromosome 13, which encodes a copper-transporting ATPase (ATP7B). Most common presentations are with liver disease or neuro- psychiatric disturbances. Kayser–Fleischer ring is the clinical hallmark of WD. caused by deposition of copper in Desçemet’s membrane of cornea. Penicillamine is the of choice.
Edema is defined and its mechanism explained with reference to the Starling's forces. The causes of localized edema and anasarca discussed.
In history taking, the site and distribution of edema, its duration, association with pain, variability, systemic illness, drug intake, trauma, radiation discussed.
The local and systemic examination described. The approach to investigation including lab tests and imaging explained.
Finally, management is discussed in short.
Aplastic anemia is one of the stem cell disorder which leads to pancytopenia in the peripheral blood and decrease production of all cell line in bone marrow. it require bone marrow transplantation to cure the patient.
PowerPoint slideshow based on the National Marfan Foundation's children's storybook, MARFAN SYNDROME A TO Z, illustrated by Lori Mitchell. Features color illustrations of real children in real-life situations experienced by kids living with marfan syndrome. Slides also feature a fun "hidden picture" game to make the story interactive.
Edema is defined and its mechanism explained with reference to the Starling's forces. The causes of localized edema and anasarca discussed.
In history taking, the site and distribution of edema, its duration, association with pain, variability, systemic illness, drug intake, trauma, radiation discussed.
The local and systemic examination described. The approach to investigation including lab tests and imaging explained.
Finally, management is discussed in short.
Aplastic anemia is one of the stem cell disorder which leads to pancytopenia in the peripheral blood and decrease production of all cell line in bone marrow. it require bone marrow transplantation to cure the patient.
PowerPoint slideshow based on the National Marfan Foundation's children's storybook, MARFAN SYNDROME A TO Z, illustrated by Lori Mitchell. Features color illustrations of real children in real-life situations experienced by kids living with marfan syndrome. Slides also feature a fun "hidden picture" game to make the story interactive.
Cardiovascular Management of
Marfan Syndrome: Implications
for Nurse Practitioners
Jonathan Yip, MN, NP, and Jo-Ann Sawatzky, PhD, RN
Readers may rec
0.17 contact hou
Association of N
the online postt
area=JNP.
The Jo594
ABSTRACT
Marfan syndrome (MFS) is a genetic disorder affecting 1 in 5,000 individuals.
The diagnosis is made using a combination of genetic testing and the revised Ghent
criteria. MFS is associated with the cardiovascular-related risks of aortic dilation and
dissection. Therefore, the main goal of medical therapy is blood pressure control using
beta-blockers and lifestyle modification. Prophylactic surgical intervention remains
the single, definitive measure in preventing dissection or rupture. Nurse practitioners
must be vigilant in caring for this population as these cardiovascular risks can be
reduced by early identification and diagnosis and timely intervention.
Keywords: aortic dilation, aortic dissection, cardiovascular complications, Marfan
syndrome
� 2014 Elsevier, Inc. All rights reserved.
arfan syndrome (MFS) is a heritable dis-
order of connective tissue. It is a relatively
Mcommon genetic disorder affecting 1
in 5,000 individuals without gender, racial, or ethnic
predilection.1-3 MFS affects multiple systems of the
body, with consequent cardiovascular-, skeletal-,
ocular-, integument-, lung-, and dural-related
symptoms.3-5 Based on earlier studies, the cause of
MFS was thought to be primarily due to the muta-
tion in the fibrillin-1 (FBN-1) gene on chromosome
15, resulting in abnormal fibrillin structure that causes
the connective tissue disorder. More recent studies
have shown that the dysfunctional transforming
growth factor (TGF)-b cytokine plays a more
critical role in extracellular matrix homeostasis or
remodeling.6-8
The diagnosis of MFS is based on both genetic
testing of FBN-1 and physical findings under the
revised Ghent criteria. Although MFS manifests in
varying degrees of severity, the most life-threatening
eive 0.79 continuing education contact hours, including
rs of pharmacology credit, approved by the American
urse Practitioners, by reading this article and completing
est and evaluation at https://cecenter.aanp.org/Program?
urnal for Nurse Practitioners - JNP
consequences include aortic dilation and dissection,
which can lead to aortic rupture and death. Hence,
it is crucial for nurse practitioners (NPs) to have
comprehensive knowledge of these complications,
as it is not uncommon for NPs to encounter MFS
patients in both acute and primary care practice.
Currently, the opportunities for early diagnosis and
the use of noninvasive serial aortic imaging, as well
as advancements in the both medical and surgical
management of MFS, have led to significant
improvement in the life expectancy of all affected
individuals.3,5 In this study we aim to provide NPs
with a comprehensive overview of MFS and offer
specific insights for the cardiovascular management
of these individuals and their families.
GENE.
Cardiovascular Management of
Marfan Syndrome: Implications
for Nurse Practitioners
Jonathan Yip, MN, NP, and Jo-Ann Sawatzky, PhD, RN
Readers may rec
0.17 contact hou
Association of N
the online postt
area=JNP.
The Jo594
ABSTRACT
Marfan syndrome (MFS) is a genetic disorder affecting 1 in 5,000 individuals.
The diagnosis is made using a combination of genetic testing and the revised Ghent
criteria. MFS is associated with the cardiovascular-related risks of aortic dilation and
dissection. Therefore, the main goal of medical therapy is blood pressure control using
beta-blockers and lifestyle modification. Prophylactic surgical intervention remains
the single, definitive measure in preventing dissection or rupture. Nurse practitioners
must be vigilant in caring for this population as these cardiovascular risks can be
reduced by early identification and diagnosis and timely intervention.
Keywords: aortic dilation, aortic dissection, cardiovascular complications, Marfan
syndrome
� 2014 Elsevier, Inc. All rights reserved.
arfan syndrome (MFS) is a heritable dis-
order of connective tissue. It is a relatively
Mcommon genetic disorder affecting 1
in 5,000 individuals without gender, racial, or ethnic
predilection.1-3 MFS affects multiple systems of the
body, with consequent cardiovascular-, skeletal-,
ocular-, integument-, lung-, and dural-related
symptoms.3-5 Based on earlier studies, the cause of
MFS was thought to be primarily due to the muta-
tion in the fibrillin-1 (FBN-1) gene on chromosome
15, resulting in abnormal fibrillin structure that causes
the connective tissue disorder. More recent studies
have shown that the dysfunctional transforming
growth factor (TGF)-b cytokine plays a more
critical role in extracellular matrix homeostasis or
remodeling.6-8
The diagnosis of MFS is based on both genetic
testing of FBN-1 and physical findings under the
revised Ghent criteria. Although MFS manifests in
varying degrees of severity, the most life-threatening
eive 0.79 continuing education contact hours, including
rs of pharmacology credit, approved by the American
urse Practitioners, by reading this article and completing
est and evaluation at https://cecenter.aanp.org/Program?
urnal for Nurse Practitioners - JNP
consequences include aortic dilation and dissection,
which can lead to aortic rupture and death. Hence,
it is crucial for nurse practitioners (NPs) to have
comprehensive knowledge of these complications,
as it is not uncommon for NPs to encounter MFS
patients in both acute and primary care practice.
Currently, the opportunities for early diagnosis and
the use of noninvasive serial aortic imaging, as well
as advancements in the both medical and surgical
management of MFS, have led to significant
improvement in the life expectancy of all affected
individuals.3,5 In this study we aim to provide NPs
with a comprehensive overview of MFS and offer
specific insights for the cardiovascular management
of these individuals and their families.
GENE ...
An overview of the 2010 Revised Ghent Nosology for Marfan Syndrome. Created to train those knowledgable of the disorder of the changes in how the disorder is diagnosed, including systemic score, z-score calculation, genetic testing, differential diagnosis, etc.
Marfan syndrome (MFS) is an inherited connective tissue disease characterized by pathological changes in the heart and blood vessels, musculoskeletal system, and eyes.
Spontaneous coronary-artery dissection (SCAD) has emerged as an important cause of myocardial infarction in young persons. SCAD occurs
primarily in women, and the prevalence of cardiovascular risk factors among
women with myocardial infarction from SCAD is lower than the prevalence of risk
factors among women with myocardial infarction from atherosclerosis.1-5 Although
SCAD is uncommon, awareness of both the disease and its angiographic
appearance has improved.6 Accurate and rapid diagnosis is paramount because the
management of acute myocardial infarction caused by SCAD differs vastly from
that of atherosclerotic myocardial infarction. SCAD can be a forme fruste of an
underlying systemic arteriopathy — namely, fibromuscular dysplasia
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Factory Supply Best Quality Pmk Oil CAS 28578–16–7 PMK Powder in Stockrebeccabio
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. Introduction
Marfan syndrome - autosomal dominant inherited disorder of
connective tissue, characterised by loss of elastic tissue,
affects numerous body systems, including the
musculoskeletal, cardiovascular, neurological, and respiratory
systems, and the skin and eyes.
3. History
Antoine Bernard-Jean
Marfan (June 23, 1858 –
February 11, 1942), a
French pediatrician.
In 1896, Marfan described
a hereditary disorder of
connective tissue in a 5 yr
old girl with
disproportionately long
limbs that later became to
be known as Marfan
syndrome
4. Epidemiology
One of the most common inherited disorders of connective
tissue
Incidence: 1 in 3000-5000 individuals
Prevalence is thought to be similar
Regardless of sex
Regardless of ethnicity
Marfan syndrome-diagnosis and management.
Curr Probl Cardiol. Jan 2008;33(1):7-39.
5. Aetiology
Caused by a variety of mutations in the FBN1 gene. FBN1
mutations have been identified in over 90 percent patients
In 75% of patients - autosomal dominant, although the
appearance of family members and degree of pathological
features may vary.
In 25% of patients - mutation occurs spontaneously and
may be associated with older paternal age.
The first fibrillin-1 gene mutation was identified in 1990.
Subsequently, over 1000 different mutations have been
identified.
6. About 10 percent of individuals with suspected MFS have no
defined FBN1 mutation. Some of these individuals may have
TGFBR1 or TGFBR2 mutations. TGFBR1/TGFBR2 mutations
more typically cause LoeysDietz syndrome (LDS), with rare
reports in association with familial thoracic aortic aneurysm
(FTAA) syndrome.
Some patients with FBN1 gene mutations do not have MFS
and instead have a related disorder such as ectopia lentis
syndrome or other diseases such as ShprintzenGoldberg
syndrome, WeillMarchesani syndrome, or stiff skin syndrome.
7. Pathophysiology
Mutations in the fibrillin-1 gene result in the production of an
abnormal fibrillin protein, leading to abnormalities in the
mechanical stability and elastic properties of connective
tissue.
More recently, research suggests that transforming growth
factor-beta is implicated in the failure of normal elastic tissue
formation.
TGFBR 1 and 2 mutations – may have similar manifestations
Cystic medial necrosis - cysts being fluid collections of mucin
and ground substance - lead to a weakening of the aortic wall
with subsequent aortic dilation and potentially aortic
dissection, aneurysms, and rupture. They also lead to a
reduction of the structural integrity of the skin, ligaments, eye
lenses, lung airways, and the spinal dura.
9. First description
5 year girl, Gabrielle P
Prominent Skeletal features - disproportionately long limbs.
She Probably had Congenital Contractual arachnodactyly!
- Not Marfan!
Revised diagnostic criteria for Marfan syndrome.
American Journal of Medical Genetics. 62 (1996)
10. Additional features described during 20th century
Ectopia Lentis (Borger; 1914)
Autosomal Dominant inheritance (Weve; 1931)
Aortic Dialatation (Etter and grover; 1943)
Aortic Dissection (Baer; 1943)
Mitral Valve Prolapse (Brown; 1975)
Dural Ectasia (Pyeritz; 1988)
Revised diagnostic criteria for Marfan syndrome.
American Journal of Medical Genetics. 62 (1996)
11. Highly variable phenotypic expression
2 cardinal features with various supportive features
Aortic root dialatation
Ectopia lentis
12. The Berlin Nosology
‘Clinical’ Classification of Heritable connective tissue
disorders (HCTD)
Described Marfan Syndrome
Major and Minor manifestations (in decreasing order of
specificity)
Skeletal
Ocular
Cardiovascular
Pulmonary
Skin
CNS
Autosomal Dominant InheritanceInternational Nosology of HCTD,1986
American Journal of Medical Genetics. (1988)
13. Relied completely on clinical criteria
Led to overdiagnosis
Specially in family members of index cases
Overlapping HCTDs
International Nosology of HCTD,1986
American Journal of Medical Genetics. (1988)
14. The Ghent Criteria
Introduced in 1996
For more accurate identification and decreasing
overdiagnosis – less weightage to less specific signs and
symptoms
Major criteria – High specificity (less likely in overlapping
disorders)
Differentiates between
Major criteria present in a system
A system ‘being involved’ – minor criterion
If a number of minor criteria present – conversion to major
criteria
Revised diagnostic criteria for Marfan syndrome.
American Journal of Medical Genetics. 62 (1996)
15.
16. Requirement for diagnosis
If Characteristic Mutation
known/AD inheritance
apparent
Major criteria in 1 system
+
2nd system ‘involved’
If family/genetic history not
significant
Major criteria in 2 systems
+
3rd system ‘involved’
Family history Major
criteria present
+
Major criteria in 1 system
+
2nd system ‘involved’
Index Case Relative of Index case
17. Limitations
Insufficient validation
Limited applicability to children
Requirement of expensive and specialized evaluation
Overdiagnosis even when Aorta not involved – clinically
less important phenotype
Dural ectasia, a major criteria, is often seen in other
connective tissue disorders (including both LDS and SGS)
18. Revised Ghent Criteria
Introduced in 2010
Emphasis on the key features of Marfan syndrome
Aortic root aneurysm/ aortic root dissection
Ectopia lentis
New systemic score assigns less specific features of Marfan
syndrome a numeric value so they are weighted properly in
the evaluation process.
Highlights the identification of additional features that would
suggest an alternative diagnosis
Provides a more precise role for molecular testing
The revised Ghent nosology for the Marfan syndrome.
J Med Genet 2010; 47:476.
19. Criteria for Marfan syndrome diagnosis in patients with no
family history
Ao (Z ≥ 2) AND ectopia lentis
Ao (Z ≥ 2) AND FBN1 mutation
Ao (Z ≥ 2) AND systemic features (≥ 7 points)
Ectopia lentis AND FBN1 associated with known aortic
involvement
Ao = aortic diameter above indicated Z-score or aortic root
dissection
20. Criteria for Marfan syndrome diagnosis in patients with a
positive family history
Ectopia lentis AND family history of MFS
Systemic features (≥ 7 points) AND family history of MFS
Ao family history of MFS
(Z ≥ 2 above 20 years, ≥ 3 below 20 years)
22. Special considerations for children (<20 yrs):
If insufficient systemic features (<7) and/or borderline
aortic root measurements (Z < 3) are present (without
FBN1 mutation) – “non-specific connective tissue
disorder” until follow-up echo evaluation shows aortic root
dilation (Z≥3).
If an FBN1 mutation is identified in sporadic or familial
cases but aortic root measurements are still Z < 3 -
“potential MFS” until the aorta reaches threshold.
23. Related disorders
Ectopia lentis syndrome
Dislocated lenses with or without systemic features AND
with an FBN1 not associated with Ao
or no FBN1
MASS (myopia, MVP, borderline aortic root dilation, striae,
skeletal findings)
Ao (Z < 2); AND systemic features ≥ 5 (with at least one
skeletal feature) without ectopia lentis
Mitral valve prolapse syndrome
MVP; AND
Ao (Z < 2); AND systemic features < 5 without ectopia
lentis
24. Aortic Disease
Aortic root disease, leading to aneurysmal dilatation, aortic
regurgitation, and dissection - main cause of morbidity and
mortality
Poor correlation between the severity of the cardiovascular
and the ocular or skeletal manifestations
Although dilated, the aorta in MFS tends to be stiffer and less
distensible
Dilatation of the aorta, often (about 25%) accompanied by
aortic regurgitation, progresses with time
50 percent of young children with MFS
60 to 80 percent of adult patients with MFS
25. Dilatation may also involve other segments of the thoracic
aorta, the abdominal aorta, the root of the pulmonary artery
or even the carotid and intracranial arteries, although much
less frequent than in LDS.
The normal range for aortic diameter varies with body size
and age - nomograms and Z-scores used to identify aortic
dilatation.
Undiagnosed and untreated MFS - frequently associated with
aortic dissection. May have a family history of dissection.
The frequency with which MFS is responsible for aortic
dissection varies with age.
50% of those under age 40
2 % of those with age 40 - 70
no patient over age 70
26. A Normal
B MFS; Ao root dialation
C Aorto Annular ectasia;
whole Asc Ao dialation
MFS; Ao root dialation
27.
28.
29.
30. Cardiac disease
Mitral valve prolapse (MVP)
Common but nonspecific – only 1 point in systemic
scoring
40-54% MFS adults; upto 90% in some series
frequency of MVP increases with age; greater in women.
Tricuspid valve prolapse may also occur.
On echo mitral leaflets elongated and redundant
either or both leaflets may prolapse
most have mild or less regurgitation
31. Approximately 25 percent of patients with MVP have
progressive disease - defined by the appearance or
worsening of clinical symptoms of mitral regurgitation or
worsening on echocardiography.
Heart failure attributable to mitral valve prolapse and
regurgitation represents a major source of morbidity and
mortality in young children with the most extreme and rapidly
progressive presentation of MFS.
Some report suggest - some patients may have a
cardiomyopathy with biventricular enlargement and generally
asymptomatic mild systolic dysfunction unrelated to valvular
disease
32. Skeletal disease
Excess linear growth of the long bones – Individuals taller
than predicted by their genetic background
Joint laxity
Paradoxically, some individuals with MFS have reduced joint
mobility, particularly of the elbow and digits - reduced elbow
extension (≤170 degrees with full extension) – 1 point to the
systemic score
Arachnodactyly — abnomally long and slender fingers
Thumb sign - entire distal phalanx protrudes beyond the
ulnar border of a clenched fist with or without the assistance
of the patient or examiner to achieve maximum adduction
33. Wrist sign - the top of the thumb covers the entire fingernail
of the fifth finger when wrapped around the contralateral wrist
Pectus deformity — Pectus carinatum - more specific for
MFS than pectus excavatum or chest asymmetry,
Hindfoot valgus — occurs with forefoot abduction and
lowering of the midfoot and should be evaluated from anterior
and posterior views.
Pes planus (flat foot) without hindfoot valgus is less specific
Generalized joint hypermobility also may occur, producing
findings that overlap with the much more common benign
joint hypermobility syndrome.
34. Abnormal US/LS and arm span/height —
disproportionately long extremities in comparison to the
length of the trunk (dolichostenomelia) - upper segment to
lower segment (US/LS) ratio is decreased and the arm span
to height ratio is increased.
The lower segment is defined as the distance from the top of
the symphysis pubis to the floor in the standing position; The
upper segment is the height minus the lower segment.
35. Thresholds for abnormal US/LS and arm span/height vary
with age and ethnicity.
Reduced US/LS is <0.85 for white adults and <0.78 for black
adults.
For children, reduced US/LS is <1 for age 0 to 5 years, <0.95
for 6 to 7 years, <0.9 for 8 to 9 years, and <0.85 above age
10 years.
Arm span measured by distance from tip of the middle finger
on one hand to the other.
Increased arm span to height ratio is >1.05 for adults.
36.
37.
38.
39. Scoliosis and kyphosis
A Cobb’s angle of at least 20 degrees (on an anterior-
posterior radiographic view of the spine, the angle between a
line drawn along the superior end plate of the superior end
vertebra and a second line drawn along the inferior end plate
of the inferior end vertebra of the scoliosis)
Exaggerated kyphotic thoracolumbar spinal curvature.
Protrusio acetabuli
Can be diagnosed by plain radiograph, computed
tomography (CT), or magnetic resonance imaging (MRI).
On an anterior-posterior pelvic film, medial protrusion of the
acetabulum ≥3 mm beyond the ilio-ischial (Kohler) line is
diagnostic.
40. Protrusio acetabuli - medial displacement of the femoral head
Medial aspect of femoral cortex is medial to the ilioischial line.
41. Facial features — dolichocephaly (reduced cephalic index or
head width/length ratio), enophthalmos, downslanting
palpebral fissures, malar hypoplasia, and retrognathia.
42. Dural ectasia
Enlargement of the spinal canal owing to progressive ectasia
of dura and neural foramina and to erosion of vertebral bone.
Usually involves the lumbosacral spine
60-90% pts on MRI/CT - sensitive but not specific sign of
MFS, is commonly seen in Loeys-Dietz syndrome and
Shprintzen-Goldberg syndrome, has been reported in the
vascular form of Ehlers-Danlos syndrome.
MRI most sensitive technique.
No correlation appears to exist between the severity of dural
ectasia and the degree of aortic dilatation.
43.
44. Ocular abnormalities
Ectopia lentis - 50 to 80 percent.
Detected on slit-lamp examination after maximal dilatation of
the pupil and the lens is usually displaced upward and
temporally. It is caused by failure of the supporting ciliary
zonules.
Myopia >3 diopters - secondary myopia due to increased axis
globe length.
Flat cornea, hypoplastic iris, hypoplastic ciliary muscle
causing decreased miosis, retinal detachment, glaucoma,
and early cataract formation. Retinal tears and detachment
are commonly bilateral.
45.
46. Pulmonary disease — Some patients develop
emphysematous changes with lung bullae predominantly in
the upper lobes, can predispose to spontaneous
pneumothorax
Skin striae — The presence of striae atrophicae contributes
one point to the systemic score if not associated with
pronounced weight changes or pregnancy and if in
uncommon location such as the mid back, lumbar region,
upper arm, axillary region, or thigh
Other — Recurrent or incisional herniae, joint hypermobility,
and high arched palate may occur but are not included in the
systemic score - nonspecific.
47. Step-by-step diagnostic
approach
History and physical examination (including slit-lamp
ophthalmic examination with pupil dilation) in conjunction with
imaging of the aortic root and the ascending, descending,
and abdominal aorta (echo, CT, MRI) are usually sufficient for
diagnosis.
Identification of risk factors
Family history of Marfan's syndrome, or of aortic dissection
or aneurysm.
There is also a weak association with high parental age.
Other historical considerations
Family history of myopia, astigmatism, strabismus,
amblyopia, premature cataract or other lens abnormalities,
glaucoma, retinal detachment, dental extraction or braces
for dental crowding, hernias, or spontaneous
48. Physical examination
Tall stature, wide arm span, high level of pubic bone, high
arched palate, arachnodactyly, positive wrist and thumb
sign, pectus excavatum, pectus carinatum, scoliosis,
striae, flat feet, thick spectacles for myopia, hernias, aortic
or mitral valve murmur may be present.
Spontaneous pneumothorax or emphysematous bullae
may present as dyspnoea.
There may be signs of heart failure due to valve disease or
cardiomyopathy.
Complete ophthalmic examination, including fundus
examination with pupil dilation - signs of lens subluxation
or dislocation, cataract, glaucoma, or retinal detachment.
May present with acute aortic dissection or rupture.
49. Initial investigations
Echocardiography, thorax CT, and thorax MRI are used
initially for aortic root imaging.
Abdominal ultrasound, CT, and MRI are used for
visualisation of the descending aorta.
CXR is performed to exclude the presence of a
pneumothorax, and may reveal emphysematous bullae.
50. Subsequent investigations
Blood screening for mutations in the fibrillin-1 (FBN1) gene
confirms the diagnosis if in doubt. Once detected, the
mutation can be used to screen other relatives, and used
for antenatal diagnosis and pre-implantation genetic
diagnosis. This test is more specific than MRI for dural
ectasia, which can also be found in Ehlers-Danlos
syndrome.
Lower spine CT scan or MRI can be performed to exclude
dural ectasia.
Plasma homocysteine levels help in unclear cases to
differentiate homocystinuria.
Skin biopsy is indicated only if Ehlers-Danlos syndrome is
suspected.
56. The diagnosis of Marfan syndrome (MFS) in familial and
sporadic cases are based upon the presence of characteristic
manifestations, particularly aortic root dilatation/dissection
and ectopia lentis, as well as other systemic features
MFS is caused by a variety of mutations in the FBN1 gene.
FBN1 mutations have been identified in over 90 percent of
patients with MFS.
Revised Ghent criteria is used for diagnosing Marfan
syndrome.
The differential diagnosis for MFS includes a variety of
conditions with phenotypic features that partially overlap the
Marfan phenotype, including disorders associated with
FBN1/2 or TGFBR1/2 mutations, as well as a variety of other
genetic disorders.
57. First degree relatives of patients with a gene mutation
associated with aortic aneurysms and/or dissection (eg,
FBN1, TGFBR1, TGFBR2, COL3A1, ACTA2, MYH11) should
undergo counseling and genetic testing. Those found to have
the genetic mutation should then undergo aortic imaging.
For patients with aortic aneurysm and/or dissection without a
known mutation, aortic imaging is recommended for first
degree relatives to identify those with asymptomatic disease.
If one or more first degree relatives are found to have
thoracic aortic dilatation, aneurysm, or dissection, then
imaging of second degree relatives is reasonable.
AHA/ACC/STS 2010 recommendations
58. Echocardiography is recommended at initial diagnosis and at
six months to assess the aortic root and ascending aorta in
patients with MFS.
Monitoring should be performed at least annually in patients
with Ao root diameter more than 4.0 cm, and biannually in
patients at higher risk (Ao root diameter more than 4.5 cm; Ao
root enlargement more than 0.5 cm per year ; family history
of Ao dissection).
AHA/ACC/STS 2010 recommendations